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    O R I G I N A L P A P ER

    If Were Going to Change Things, It Has to Be Systemic:Systems Change in Childrens Mental Health

    Sharon Hodges Kathleen Ferreira

    Nathaniel Israel

    Society for Community Research and Action 2012

    Abstract Communities that undertake systems change in

    accordance with the system of care philosophy commit tocreating new systems entities for children and adolescents

    with serious emotional disturbance. These new entities are

    values-based, voluntary, and cross-agency alliances that

    include formal child-serving entities, youth, and families.

    Describing the scope and intent of one such implementa-

    tion of systems of care, a mental health administrator

    commented, If were going to change things, it has to be

    systemic (B. Baxter, personal communication, December

    2, 2005). This paper explores the concept of systemic in

    the context of systems of care. Systems theory is used to

    understand strategies of purposeful systems change

    undertaken by stakeholders in established system of carecommunities. The paper presents a conceptual model of

    systems change for systems of care that is grounded in data

    from a national study of system of care implementation

    (Research and Training Center for Childrens Mental

    Health in Case Studies of system implementation: Holistic

    approaches to studying community-based systems of care:

    Study 2, University of South Florida, Louis de la Parte

    Florida Mental Health Institute, Research and Training

    Center for Childrens Mental Health, Tampa, FL, 2004).

    The model is based on Soft Systems Methodology, an

    application of systems theory developed to facilitate

    practical action around systems change in human systems

    (Checkland in Systems thinking, systems practice, Wiley,

    Chichester, 1999). The implications of these findings to

    real world actions associated with systems change in sys-tems of care are discussed.

    Keywords Systems of care Mental health

    Systems theory Soft systems methodology

    Introduction

    Systems change efforts in the public sector are often

    undertaken with the explicit goals of improving systems

    functioning and better serving community needs. This is

    particularly so when such efforts areconceived in response tothe perceived failure of public services to achieve optimal

    community outcomes. In childrens mental health, a crisis

    brought about by inadequate and fragmented services for

    children with serious emotional disturbance (SED) is being

    addressed though a systems change effort widely known as

    systems of care (Cook and Kilmer this issue; Knitzer 1982;

    Stroul and Blau 2008; Stroul and Friedman 1994). The sys-

    tem of care (SOC) concept was conceived as a values-based

    organizational philosophy that focuses systems change on

    building collaboration across child-serving sectors, families,

    and youth for the purpose of improving access to an expan-

    ded array of coordinated community-based services for

    children with SED (Stroul 1993; Stroul and Friedman 1986).

    Referenced in both the Surgeon Generals report on Chil-

    drens Mental Health (U.S. Department of Health and

    Human Services [USDHHS] 1999) and the report of The

    Presidents New Freedom Commission on Mental Health

    (2003), the Comprehensive Community Mental Health

    Services for Children and Their Families Program

    (CMHI) has provided nearly $1.5 billion dollars to states,

    regions, counties, territories, Native American and tribal

    S. Hodges (&) K. FerreiraDepartment of Child and Family Studies, MHC 2437,University of South Florida, 13301 Bruce B. Downs Blvd.,Tampa, FL 33612, USAe-mail: [email protected]

    N. IsraelRDN Associates, Berkeley, CA, USA

    123

    Am J Community Psychol

    DOI 10.1007/s10464-012-9491-0

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    organizations, and the District of Columbia for the purpose

    of creating comprehensive, community-based mental health

    services through systems of care (ICF Macro 2010). In

    addition, systems of care have been supported with millions

    of dollars made available to state and local governments

    through programs such as the Child and Adolescent Service

    System Program (CASSP) and the State Infrastructure Grant

    Program. Given the level of funding support, the SOC phi-losophy has arguably become the de facto child mental

    health policy in the United States.

    Communities that undertake change in accordance with

    the SOC philosophy commit to developing integrated ser-

    vices for children and adolescents with SED and their

    families that are dictated by the needs and strengths of the

    child and family, are community-based, and are culturally

    competent (Stroul and Friedman 1986, 1994). The aim of

    such systems change is for children and families to have

    access to a continuum of appropriate services and supports

    unencumbered by multi-agency jurisdictional fragmenta-

    tion. Describing the scope and intent of one such imple-mentation of systems of care in a 22-county behavioral

    health region of Nebraska, a mental health administrator

    commented, If were going to change things, it has to be

    systemic (B. Baxter, personal communication, December

    2, 2005). But what does it mean to be systemic in SOC

    implementation? The originators of the SOC philosophy

    (Stroul and Friedman 1986, 1994) aswell asothers who have

    developed practical resources detailing the components of

    SOC implementation (e.g., Pires 2002; Stroul and Blau

    2008) have used the concept of a system without explicitly

    grounding the philosophy in systems theory. However, the

    public dialog around systems of care has more recentlyshifted to include some discussion of systems theory (e.g.,

    Foster-Fishman and Droege 2010; Friedman 2010; Hodges

    et al. 2010). We believe that an explicit application of sys-

    tems theory in systems of care can improve SOC imple-

    mentation by providing a useful construct for understanding

    the interdependencies created by systems of care as well as

    key strategies for facilitating SOC development.

    Von Bertalanffy (1968, p. 37) describes systems theory

    as a general science of wholeness and defines a system

    as individual elements of an organism or social phenome-

    non that when taken together create a complex, emergent

    whole. Systems theory characterizes human systems as

    continuously constructed and reconstructed by individuals

    and groups in an ongoing process that reflects the com-

    plexity of real world experience (Capra 1996, 2002;

    Checkland 1999; Senge 1990). From the perspective of

    community psychology, Foster-Fishman et al. (2007) note

    that the term system can be used to describe a wide array of

    phenomena including a family, neighborhood, organiza-

    tion, school district, human service delivery network,

    coalition of organizations, or the federal welfare system.

    Further, more recent work by Peirson et al. ( 2011) notes

    that in these synergistic systems, broad objectives can be

    achieved that could not be accomplished by any single

    element of the system.

    Systems change can be thought of as a process of

    transformation in the existing structure, function, and/or

    culture of a system (Peirson et al. 2011, p. 308). In response

    to the challenge of understanding and facilitating systemschange in human service settings, an increasingly rich dialog

    has developed regarding the application of systems theory to

    comprehensive community initiatives (Cook and Kilmer

    this issue; Foster-Fishman and Behrens 2007; Hodges and

    Ferreira 2010a; Peirson et al. 2011; White 2000). This paper

    will explore the concept of systemic in the context of

    systems of care, reporting findings of a 5-year study of

    system implementation in six established systems of care1

    (Research and Training Center for Childrens Mental Health

    2004). Applied to systems of care, systems theory can be

    used to describe changes in service delivery networks for

    children with serious emotional disturbance and their fam-ilies. As dynamic entities, the development of systems of

    care must be sensitive to local conditions and require

    understanding of how changes in the component parts might

    affect the emergent whole. Systems theory will be used to

    understand strategies of purposeful systems change under-

    taken by stakeholders in established SOC communities that

    were identified through a national study of SOC imple-

    mentation (Research and Training Center for Childrens

    Mental Health 2004). The paper will present a conceptual

    model of systems change for systems of care that is grounded

    in data from this study. The model is based on Soft Systems

    Methodology, an application of systems theory developed tofacilitate practical action around systems change in human

    systems (Checkland 1999). Finally, the implications of these

    findings to actions associated with systems change in sys-

    tems of care will be discussed.

    Being Systemic in Systems of Care

    A great deal is known about the changes to the structure,

    organization, and availability of services that are intended

    by SOC implementation (Hoagwood et al. 2001;

    Rosenblatt 1998; Stroul 1993). This implementation,

    however, is significantly challenged by a lack of under-

    standing regarding the processes of systems change as well

    as how various systems change activities interact to

    establish well-functioning systems of care (Hernandez and

    Hodges 2003; Research and Training Center for Childrens

    Mental Health 2004). The literature suggests that although

    1 Case Studies of System Implementation is believed to be the firstresearch study to specifically apply systems theory to systems of care.

    Am J Community Psychol

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    ideal systems serving children and youth with SED and

    their families would be implemented as a single, bounded,

    well-defined set of policies, regulations, and service prac-

    tices, the reality of SOC implementation is quite different

    (Cook and Kilmer 2010). The implementation of systems

    of care is complex due to the numerous components of any

    given system, incremental nature of system development,

    variations in community needs and strengths, changes inleadership and support over time, and the difficult balance

    of individual agency mandates with interagency collabo-

    rative goals (Hodges et al. 2006a, b, c, 2007a, b, 2008,

    2009a). Shifts in political will and support experienced by

    community-based efforts in general suggest that systems

    change is difficult and often unpredictable work, and not

    well matched to ways of thinking that presuppose orderly,

    stepwise change (Hernandez and Hodges 2003).

    Soft Systems Methodology

    Systems theory offers a wide variety of approaches tounderstanding change in human systems including eth-

    nography (Agar 2004), learning organizations (Senge

    1990), systems dynamic modeling (Sterman 2002), and

    complex systems (Plsek and Greenhalgh 2001). The

    importance of using theory in the development of con-

    ceptual models of new and improved systems has been

    highlighted by Peirson et al. (2011). This is particularly

    true in systems of care because of the varied and complex

    nature of these systems change efforts. Soft systems

    methodology (SSM) provides an opportunity to develop a

    conceptual model of systems change through the use of

    systems thinking as a process to help us organize ourthoughts (Checkland 1999). In SSM, conceptual models

    derived from systems thinking are used to formulate fea-

    sible and desirable systems practice in real world

    change efforts (Checkland 1999). The term soft in SSM

    stresses that human systems are not fixed entities; the

    process of inquiry is systemic. This calls for a different way

    of looking at change, one focused on evolving systems and

    strategies rather than on linear steps or mechanical

    parts. As a process of inquiry, SSM can be used to nav-

    igate between the real world experience of systems chal-

    lenges and a more conceptual world of thinking

    systemically about these challenges in order to produce

    conceptual models for carrying out systems change. The

    models derived using SSM are intended to be tested in real

    world settings by targeting purposeful systems change

    activities that are based on the conceptual model.

    Foster-Fishman and Behrens (2007) note that the model

    of causation in which X predicts Y is ill-equipped to deal

    with the complexities of systems change efforts. SSM is a

    particularly useful tool for understanding systems change

    in the complex context of systems of care because it avoids

    the reductionist approaches necessary to define systems

    change in terms of discrete independent and dependent

    variables. This is accomplished by a sound grounding of

    systems thinking in the real world through the construction

    of root definitions of a systems intent and rich pic-

    tures of a problem situation (Checkland 1999 p. 317).

    According to SSM, root definitions are succinct statements

    that describe a system and provide an explicit under-standing of the intent and context of systems change. Root

    definitions should include facets of a system that can

    support problem solving and hypothesizing strategies for

    systems change. Rich pictures are the expression of

    stakeholder experiences compiled by investigators. In SSM

    rich pictures describe multiple stakeholder experiences of

    the structures, processes, and relationships that affect sys-

    tems change (Checkland 1999). The goal of rich pictures

    is to capture the variety of stakeholder experiences without

    prematurely imposing a model of systems change.

    Using both rich pictures derived from the experiences of

    system stakeholders and a root definition expressing thecriteria relevant to systems change, a conceptual model of

    systems change can be developed. The modeling process is

    iterative and should involve discussion and debate with

    those involved in activities of systems change. In addition,

    the development of a conceptual model should be

    increasingly oriented toward identifying practical action

    related to systems change (Checkland 1999).

    Applying SSM in Systems of Care

    An application of SSM to understanding systems of care

    implementation is shown in Fig. 1. The process of systemschange, somewhat simplified from the process described by

    Checkland, integrates real world practice with systems

    thinking activities, creating a complete learning cycle.

    In this figure, real world practice indicates activities

    occurring above the dashed line, and systems thinking

    refers to activities occurring below the dashed line. The

    root definition of systems of care, indicating the intent and

    context of systems change, is represented by the dotted

    background and permeates both real world practice and

    systems thinking activities. Foster-Fishman et al. (2007)

    suggest that many systems change efforts in the human

    services and community change fields ignore the systemic

    nature of the contexts they target. SSM establishes the

    context of systems change through the use of root defini-

    tions that elaborate an intended transformation by articu-

    lating the beneficiaries and participants of the systems

    change, potential environmental constraints, and the world

    view that articulates intent and gives this change meaning.

    For the purpose of this application of SSM, the root

    definition for systems of care includes three components

    of context that affect SOC implementation regardless of

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    cultural, political, or demographic variation (Hodges et al.

    2010). SOC implementation:

    1. is based on the values foundational to the SOC

    philosophy. The fundamental association of systems

    of care with a strong values base provides an explicit

    understanding of the intent of systems change as well

    as potential beneficiaries and participants in systemschange processes (Stroul and Blau 2010).

    2. includes voluntary alliances of child-serving entities.

    Because participation in systems of care is rarely

    mandated, roles, responsibilities, and relationships are

    most often formalized only by cross-agency memo-

    randa of understanding. Membership will vary over

    time according to the willingness and ability of

    partners to participate in system activities (Child

    Adolescent and Family Branch 2006).

    3. integrates cross-agency networks of formal child-

    serving agencies as well as informal supports that

    include both youth and families. The values andprinciples of systems of care specify that systems

    change should include multiple child serving agencies

    (e.g., child welfare, education, juvenile justice) in

    addition to the public mental health entity (Child

    Adolescent and Family Branch 2006).

    Because root definitions establish the context for systems

    change, they are foundational to the three stages of the SSM

    process. Stage 1 of SSM represents real world experiences

    of children, families, service providers, administrators, and

    policy makers in service systems for children with SED and

    their families. These experiences of service delivery can be

    used to generate rich pictures that are purposefully applied to

    systems thinking. Stage 2 involves systems thinking and the

    development of a conceptual model of systems change. Rich

    pictures from Stage 1 inform this conceptual model. The

    double arrows between Stages 1 and 2 represent iterations

    required to incorporate real world experiences into systemsthinking in order to develop a model of activities that ade-

    quately captures the complexity of SOC implementation.

    Stage 3 offers the opportunity to apply systems thinking

    in systems of care. In Stage 3, leaders of systems change in

    individual systems of care assess the feasibility and desir-

    ability of the conceptual model in order to identify specific

    actions that they can apply in their own systems change

    work. The arrow linking Stages 2 and 3 represents the

    transition from systems thinking back to real world appli-

    cation. Tests of the conceptual model in Stage 3 by prac-

    titioners of systems change generate new experiences of

    systems of care (represented by the arrow linking Stages

    31) and completing the cycle of learning that is reflected

    throughout the entire SSM process. SSM allows SOC

    implementers to reflect on the unique circumstances of

    their individual system implementation efforts. As such, an

    SSM model of systems change can never be expected to

    provide a prescriptive tool or a precise set of actions to be

    applied to all systems of care. Rather, the model articulates

    broad activities and relationships intended to be adapted in

    specific systems change efforts.

    Root

    Definition

    Systems thinking

    Real world practice

    Stage 2. Develop conceptual model

    of systems change in systems of care

    using rich pictures of real world

    experience

    Stage 1. Experiences of

    service systems for

    children with serious

    emotional disturbance

    Stage 3. Implement

    actions aimed atsystem of care

    Learning Cycle

    Fig. 1 Soft systemsmethodology process applied tosystems of care

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    A Conceptual Model of Systems Change in Systems

    of Care

    Case Studies of System Implementation (CSSI) used SSM

    as a framework to investigate factors that were considered

    critical to systems change by local system implementers

    (Research and Training Center for Childrens Mental

    Health 2004). Investigators found that SSM supportedsystems thinking in the context of SOC implementation

    described above. The study investigated how local com-

    munities effect purposeful systems change in order to

    achieve outcomes for a local population of children with

    SED; how local context influences SOC development; and

    why and under what conditions specific system imple-

    mentation factors are critical to successful SOC develop-

    ment. Based on these data, the research team developed a

    conceptual model of SOC implementation informed by the

    experiences of individuals who had undertaken SOC

    implementation and had sustained their efforts over time.

    Method

    CSSI used a multi-site embedded case study design (Yin

    2003) to examine systems change. This was the first such

    study of the process of systems change within systems of

    care. Six systems were identified through a national nom-

    ination process and selected for this study after preliminary

    data collection that included extensive document review

    and targeted telephone interviews. Site selection criteria

    included that participating systems have: (1) an identified

    population of children/youth with SED; (2) clearly identi-

    fied goals for this population that were consistent with SOCvalues and principles; (3) active implementation of strate-

    gies intended to achieve these goals; (4) evidence of sys-

    tems change as demonstrated by outcome data indicating

    progress toward these goals; (5) demonstrated sustainabil-

    ity of systems change over time; and (6) a willingness to

    reflect on both successes and challenges in systems change.

    The sampling strategy was intended to yield rich pictures

    of the experience of systems change in established systems

    of care as well as a variety of cultural, political, and

    demographic SOC contexts.

    Between August 2005 and May 2008, the research team

    gathered data in six established systems of care: Placer

    County, CA; Region 3, NE; the State of Hawaii; Santa

    Cruz County, CA, Marion County, IN; and Westchester

    County, NY. Data collection included semi-structured key

    informant interviews with administrators, managers, direct

    service staff and families focused on their experience of

    system development and factors they believed to be critical

    to systems change; direct observation of naturally occur-

    ring cross-agency planning and placement meetings;

    review of system documents at the state and local levels;

    the identification of systems change strategies by a group

    of key stakeholders and rating of these strategies by

    interview participants; and a review of aggregate outcome

    data. In total, these data comprise a qualitative data base

    that includes: 307 documents that provide organization

    level data related to goals and intent of systems change in a

    historical context; 268 transcribed interviews that provide

    individual perspectives regarding factors that supportedand impeded systems change efforts; 41 sets of observation

    notes of naturally occurring meetings for the purpose of

    offering confirmation or disconfirmation of the presence of

    identified implementation factors; 6 sets of stakeholder-

    identified factors considered critical to system develop-

    ment; and 113 ratings exercises for the purpose of

    exploring multiple perspectives on the definition, effec-

    tiveness, and difficulty in implementing the identified

    factors. Participants gave written informed consent for their

    participation in the study.

    The standard for team-based qualitative analysis

    requires that data be coded individually by multiple teammembers and then compared and discussed regularly

    as themes are identified (Guest and MacQueen 2008;

    LeCompte and Schensul 1999; Miles and Huberman 1994;

    Silverman et al. 1990). These conventions were used in this

    analysis, with team members coding data using a priori

    codes developed from a shared definition of systems of

    care (Hodges et al. 2010) and driven by research questions

    focused on identifying structures, processes, and relation-

    ships that support or impede systems change. Although

    codes were identified a priori, the team maintained a pro-

    cess flexible enough to allow for modification as new

    terms, patterns, or themes were identified by the team as itsought to answer the research questions.

    Using SSM as a guiding framework, CSSI data yielded

    rich pictures of systems change in the form of site-based

    reports produced for six participating systems and subse-

    quently used to inform the conceptual model. The analysis

    was iterative, involving considerable interaction with key

    research participants at each of the participating systems

    for the purpose of ensuring accuracy of reported findings

    (Creswell 2003; Miles and Huberman 1994). In addition to

    producing site-based reports (http://rtckids.fmhi.usf.edu/

    cssi/default.cfm), the research team worked collaboratively

    with system participants to explore specific aspects of the

    systems change strategies in more depth and disseminate

    findings in both research and community settings (Baxter

    2007, 2010; Brogan 2007; Cervine 2007; Hodges and

    Ferreira 2010a; Hodges et al. 2007b, 2009b; Rotto and

    McIntyre 2010). As a whole, the data collection and

    analysis, formulation of a conceptual model, and dissemi-

    nation of study results reflect the SSM learning cycle of

    incorporating stakeholder experiences of systems for chil-

    dren with SED into systems thinking and then making them

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    http://rtckids.fmhi.usf.edu/cssi/default.cfmhttp://rtckids.fmhi.usf.edu/cssi/default.cfmhttp://rtckids.fmhi.usf.edu/cssi/default.cfmhttp://rtckids.fmhi.usf.edu/cssi/default.cfm
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    available for application in SOC communities (as illus-

    trated in Fig. 1).

    Findings

    The analysis of CSSI data resulted in a conceptual model of

    systems change in systems of care. CSSI findings described

    below represent the systems thinking component of theSSM process (Stage 2) for systems of care. Figure 2

    illustrates the conceptual model for creating change in

    systems of care. The core components of this model

    include values-based persuasion, shared goals and actions,

    collaborative structures, value-based outcomes, and system

    information flow.

    Initiating Systems Change

    CSSI data indicate that systems change within study sites

    was often initiated in response to system conditions that

    supported categorical and highly restrictive services. Datafurther indicate that to address concerns regarding service

    rationing, restrictive placement, cultural competence, and

    the need for family-driven care, initial strategies for sys-

    tems change often involved efforts to extend system of care

    values and beliefs beyond the mental health service system

    to include the child welfare, juvenile probation, and

    education service sectors as well as youth and families

    (1. Value-Based Persuasion). In many cases, SOC values

    and principles were introduced to private community-based

    organizations and providers with the intended impact that

    SOC values would permeate the entire community. Data

    indicate that persuasive actions intended to shift values and

    beliefs are essential to initiating the process of systems

    change in systems of care. Even in systems in which the

    immediate impetus for systems change involved some level

    of mandate such as court involvement, the system leadersindicated that external triggers such as judicial oversight

    provided welcome leverage to promote change. To be

    effective, these actions should provide concrete examples

    of how the alignment of service planning and delivery with

    SOC values will result in benefit to children and their

    families. These actions should also include open discussion

    about how SOC values and beliefs can result in benefit to

    system partners in the form of improved system function-

    ing that is accomplished through increased trust, com-

    mitment, and shared responsibility. Finally, persuasive

    actions around SOC values must champion the belief that

    improvement is possible and that responsiveness andcommitment to change will enable collaborators to tran-

    scend the fragmented conditions of service delivery.

    Cross-site data indicate that shifts in values and beliefs

    have great power to leverage systems change because

    values and beliefs have potential to guide all other actions

    taken within the system. Participating systems were pur-

    poseful and consistent in their values-based persuasion

    including having them reproduced and publicly posted in

    1. Value-Based

    Persuasion

    2. Shared Expectations for

    Outcomes - Process - Planning

    3. System Partners

    Take Action4. Develop

    Collaborative

    Structures

    SystemInformation

    5. Value-Based

    Outcomes

    Systems thinking

    Stage 1

    Stage 2

    Stage 3

    Fig. 2 Conceptual model of systems change in systems of care

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    common areas and meeting spaces. Westchester County,

    NY provides grounding in SOC values and principles

    through a SOC training curriculum developed for the new

    staff of cross-agency partners. This training is often led by

    family members, an active demonstration of the SOC value

    for family-driven care. The value for strengths-based ser-

    vice planning that is fundamental to SOC work with chil-

    dren and families is reinforced with administrators andpolicymakers in Marion County, IN by including a dis-

    cussion of community and system strengths as the first

    agenda item in cross-agency planning meetings. Early and

    consistent efforts to create wide exposure to SOC values

    and beliefs provide strong impetus for change. The data

    also indicate that the emphasis on values and beliefs pro-

    vides a significant anchor for sustaining collaboration in

    systems of care.

    Goals and Actions

    CSSI data indicate that system goals make stakeholdervalues and beliefs concrete and orient system activity

    toward purposeful actions used to create systems change

    (2. Shared Expectations). As SOC values and beliefs begin

    to permeate the system, stakeholders use goals to establish

    shared expectations related to system implementation.

    These should include: outcome goals such as the reduction

    of out-of-home placements; process goals such as

    increasing culturally competent and individualized care;

    and planning goals related to future action. Establishing

    shared expectations is intended to bring systems under the

    influence of a single plan grounded in SOC values and

    principles and can be used to set agreed-upon targets foraction across system partners. For example, SOC stake-

    holders who decide to reduce restrictive placements across

    multiple domains may target actions that include initiating

    mental health assessments at all points of entry and the

    diversion of youth with identified mental health needs into

    more clinically appropriate community-based services and

    supports.

    Goals related to cross-agency collaboration can also

    support changes in how systems respond or adapt to their

    local environment through the creation of innovative ser-

    vices and supports. For example, system partners in Santa

    Cruz, CA established therapeutic group homes and a

    clean and sober school for youth with substance abuse

    challenges. In Region 3, NE, child welfare and mental

    health partnered to develop post adoption services and

    supports for families involved in high needs adoptions.

    Goals also enable action by helping system stakeholders

    define a systems scope and boundaries. Hawaiis articu-

    lation of goals for core system practices provided both

    explicit and implicit rules about interagency boundaries

    and appropriate day-to-day action.

    CSSI data indicate that shared values and expectations

    are, however, insufficient to implement or sustain systems

    change. It is only when system partners take action that

    values and goals become meaningful (3. System Partners

    Take Action). Otherwise, the system of care exists only as

    an expression of intent. CSSI data indicate there was a

    point in time when local stakeholders recognized that the

    traditional system structures were inadequate for achievingfamily-driven, culturally competent, community-based

    care. This recognition took shape differently across com-

    munities. For example in Hawaii, this played out in the

    form of a court-ordered mandate to implement systems of

    care; in Placer County, a Juvenile Court judge brought

    agencies together; Santa Cruz stakeholders came to action

    through their participation in the development of statewide

    SOC legislation; and in Region 3, reading the original SOC

    monograph (Stroul and Friedman 1986) inspired change. In

    each system, stakeholders decided not to accept the tradi-

    tional system structure as given and took values-based

    action to intervene strategically in the structures, processesand relationships of the traditional system.

    Collaborative Structures

    Structural changes are those related to specified roles,

    responsibilities, and authorities that enable a system to

    perform its functions. CSSI data indicate that the devel-

    opment of collaborative structures can be used as a tool of

    systems change in order to institutionalize SOC values in

    day to day practice (4. Develop Collaborative Structures).

    Collaborative structures include changes in the physical

    arrangement of services such as the co-location of cross-agency staff, changes in budgetary authorities that facilitate

    decision making regarding service eligibility and place-

    ment, and the creation of cross-agency liaisons to facilitate

    smooth transition of children across environments such as

    home and school. CSSI data indicate that collaborative

    structures are often supported by interagency MOUs that

    provide clear guidance around decision making and con-

    flict resolution processes. Many also require annual review,

    revision, and recommitment by collaborating partners so

    that broader changes and adaptations can be incorporated.

    Such collaborative structures can be used to moderate the

    impact of existing rules and regulations so that new system

    responses are more aligned with SOC values and princi-

    ples. For example, Placer County, CA moderated the tra-

    ditional single agency structure for judicial out-of-home

    placement recommendations by creating a multi-agency

    placement review team with responsibility to put forth a

    shared judicial recommendation. It is important to note that

    collaborative structures are limited in their impact in that

    they function as a catalyst for systems change only to

    the degree that they are anchored in shared values and

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    expectations. CSSI data indicate that without strong

    grounding in shared SOC values and expectations, struc-

    tural changes are unlikely to facilitate or sustain the posi-

    tive outcomes intended by systems change efforts.

    The Role of System Information

    CSSI data indicate that the communication of information,both formal and informal, is a key mechanism for facili-

    tating systems change across all components of the con-

    ceptual model (System Information). The form and format

    of information exchange can include the formal review of

    data at regular meetings as well as day-to-day conversa-

    tions among cross-agency partners and family advocates

    that are enabled by the co-location of services. The struc-

    ture and availability of system information supports an

    informed responsiveness to local conditions among system

    partners, reinforcing system values and beliefs and

    expanding the knowledge of system participants. For

    example, information systems that provide system partnersreal time child placement and cost data supports the value

    of youth being served in least restrictive and most clinically

    appropriate community-based settings. In addition, infor-

    mation availability allows partners to take action in

    response to local needs and to make system adaptations as

    local conditions or concerns change. CSSI data indicate

    that when the content of system feedback is both timely

    and relevant to issues of system performance, it can support

    flexibility and responsiveness of decision making. In

    addition, the structure and availability of information can

    be strategically designed to support achieving specific

    agreed-upon goals.Information flow is comprised of multiple activities that

    occur in real time rather than a singular effort that is

    sequenced in relation to the other activities of systems

    change. Because activities associated with information

    flow affect all activities of systems change, they can be

    used incrementally to shape the direction of this change.

    All of the systems participating in CSSI established mul-

    tiple processes for sharing SOC results with system part-

    ners and used information flow to create opportunities for

    discussion and shared decision making. For this reason,

    system information is not represented as a numbered

    activity in the conceptual model, but instead as a set of

    related activities that link the other systems change activ-

    ities together in iterative cycle of change.

    Value-Based Outcomes

    CSSI data indicate that, over time, system partners are able

    to produce outcomes more in keeping with the expressed

    values of systems of care such as individualized, family-

    driven, culturally and linguistically competent care

    (5. Value-Based Outcomes). Examples of this shift to value-

    based system outcomes abound in the rich pictures of study

    participants. Placer County stakeholders strategically inter-

    rupted their cycle of group home placements by providing

    home-based and wraparound care. Savings from the reduc-

    tion of more restrictive placements allowed the expansion of

    day treatment and other community-based services for

    troubled youth. Hawaii stakeholders interrupted the cycle ofout-of-state placements and redirected resources to the

    development of community-based care by building local

    case management services and evidence-based practices.

    Region 3 Behavioral Health Services in Nebraska created

    the Professional Partner Program, an intensive therapeutic

    care management program that uses the wraparound

    approach in coordination with family teams. Outcomes

    demonstrated included a reduction in out-of-home place-

    ments and juvenile crime as well as improvement in school

    performance and attendance. It also reduced the number of

    children and youth who were being made state wards simply

    to gain access to services. Santa Cruz stakeholders inter-rupted the cycle of office-based services by moving most of

    their service delivery time into the community. This shift has

    supported the growth of a community-based system that

    extends beyond agency partners to engage families and

    community-based providers.

    Discussion

    What does it mean to be systemic in SOC implemen-

    tation? How do the systems change activities represented in

    the conceptual model moderate traditional service deliveryoutcomes? Study participants described their initial system

    conditions as driven by federal and state regulatory struc-

    tures that enforced criteria restricting eligibility for services

    and supports, reduced the range of community-based ser-

    vices, and reinforced categorical funding. Although rarely

    explicit regarding values and goals, data indicate that the

    traditional service delivery structures often rewarded ser-

    vice rationing, restrictive placement, and professional-dri-

    ven care over family-driven, culturally competent, and

    community-based care. Stakeholders in the participating

    systems initiated systems change through actions designed

    to interrupt aspects of the traditional system functioning

    that they believed led to outcomes such as high rates of out-

    of-community placements and the use of restrictive care

    settings. The net effect of their systems change activities

    persuasive activities around values and beliefs, establishing

    shared system goals, anchoring actions in SOC values,

    developing collaborative structures, and infusing their

    systems with informationwas a shift away from the tra-

    ditional structure-driven outcomes to outcomes that were

    directed by explicit values and beliefs.

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    Six lessons derived from the systems change experi-

    ences within these sites can be applied in other systems

    change initiatives:

    1. Create an early and consistent focus on values and

    beliefs. This can be accomplished by system leaders

    introducing system of care values to potential system

    partners with a particular focus on how these valueswill allow partners to better serve the children and

    families in their care. The emphasis on values and

    beliefs provides a significant anchor for system

    development regardless of the challenges faced. For

    example, responding to a series of fire setting incidents

    committed by youth with emotional disturbance,

    Westchester County, NY system leaders brought

    together mental health, juvenile justice and fire

    department personnel to develop a community-based

    response that would meet the individual needs of these

    youth in a less restrictive and more clinically appro-

    priate way.2. Translate shared beliefs into shared responsibility and

    shared action. In doing so, system leaders can cultivate

    specific opportunities for partners to take collaborative

    action as a strategy to empower change and achieve

    value-based outcomes. For example, private non-profit

    mental health agencies in Marion County, IN physi-

    cally moved mental health staff to centrally located

    interagency care coordination teams so they could

    contribute therapeutic services to children and youth

    being served by multiple public agencies including

    education, juvenile justice, and child welfare. These

    staff worked as key members of the interagency teams,but remained on the payroll of their home agencies.

    3. Recognize that opportunities for action related to

    systems change are not linear. Planning is an impor-

    tant component of system implementation, but system

    implementers must take advantage of unanticipated

    opportunities to leverage systems change when and

    where they occur. For example, realizing that their

    outcome and cost data showed significant savings

    resulting from their integrated care coordination unit,

    system leaders in Region 3, NE convinced funders to

    reinvest dollars saved into an early intervention care

    coordination program. This response to an unantici-pated opportunity was not part of their strategic plan

    but aligned well with broader SOC goals.

    4. Know that being concrete does not mean being static.

    Being concrete about values and intent of systems of

    care allows stakeholders to be flexible in system

    response and proactive in system development. For

    example, faced with high numbers of youth served

    out of state and in restrictive settings, system

    leaders in Hawaii developed a menu of appropriate

    evidence-based practices and guidelines for imple-

    mentation through contract providers. This facilitated

    the return of children and youth to services in their

    home communities and established a broad array of

    potential services allowing the system to individualize

    services and supports for children and families. In

    addition, ongoing quality improvement data supported

    their ability to periodically assess and modify the typesand dosage of evidence-based practices needed in

    individual communities.

    5. Structural change, without a solid anchor in values

    and beliefs, rarely has the sustained positive impact

    that SOC implementers seek. Establishing an inter-

    agency governance body is a common structural

    change made in systems of care. When SOC values

    are not shared across members, activities requiring

    shared responsibility and action are impeded. System

    leaders work diligently to promote values and beliefs

    in younger and less experienced staff to minimize the

    impact of retirement and other forms of attrition. Forexample, Placer County, CA initiated formal training

    in SOC values and beliefs for future governance

    members to mitigate the impact of these transitions.

    6. The system emerges from the individual choices and

    actions of stakeholders throughout the system. This

    includes family members, youth, front-line staff, and

    community partners. To support and reinforce stake-

    holder actions that are in keeping with SOC values and

    principles, system partners provide ongoing SOC

    training to a broad array of stakeholders. SOC values

    are then made concrete for stakeholders by embedding

    small actions into day-to-day work. For example, inkeeping with the SOC value of being strengths based,

    trainings, interagency meetings, family team meetings,

    governance meetings that make up a system of care

    frequently begin with a discussion of strengths.

    Closing the Loop on System Learning

    The SSM framework requires integrating conceptualiza-

    tions of systems change into real world application in order

    to complete the learning cycle. For CSSI, this required

    disseminating research findings in real time and in such away that supported a link between research evidence and

    action. The research team employed a multi-level dissem-

    ination strategy initially grounded in community action

    (Hodges and Ferreira 2010b). Building upon site-based

    reports intended for local reflection and advocacy, dis-

    semination was expanded to state and national policy and

    practice audiences as well as the research community as

    cross-site findings were incorporated. The trajectory of

    research dissemination included the site-based reports,

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    nationally disseminated issue briefs, invited national train-

    ings and development of a community workbook based on

    study findings (Hodges and Ferreira 2009), the use of

    findings in graduate and in-service curricula in childrens

    mental health, and peer-review publications that include a

    book chapter and journal special issue. Although CSSI did

    not track specific uses of the conceptual model in commu-

    nity-level systems change initiatives, wide dissemination ofCSSI products is indicated by documented web-based

    downloads that includes 45,826 downloads of site-based

    reports and 41,484 downloads of issue briefs (CSSI prod-

    ucts available at http://rtckids.fmhi.usf.edu/cssi/default.

    cfm).

    Conclusions and Next Steps

    This paper focused on systems thinking and the use of SSM

    to develop a conceptual model of systems change that is

    based on strategies undertaken by stakeholders in estab-lished systems of care. The research team found that SSM

    offered a useful construct for investigating systems change

    resulting in a model that can be applied broadly by system

    implementers to better understand the interdependencies

    and the shifting system boundaries inherent in systems of

    care. Although the findings of this study indicate that sys-

    temic change is not step-wise in a linear sense, the preem-

    inence of establishing value-based persuasion and shared

    expectations over implementing structural change does

    suggest the importance of prioritizing stakeholder actions.

    SSM is particularly useful in that it offers an alternative to

    discrete checklists of interventions and sets of rules forsystems change that imply that change is a linear function in

    which certain actions yield predictable system results.

    The conceptual model presented in this paper identifies

    key components of the systems change process in systems of

    care and clarifies the relationships among these components.

    The value of SSM and systems thinking is that it allows SOC

    stakeholders to focus on the whole of system transformation

    while maintaining attention to the component parts of their

    intended change. In doing so, systems thinking provides

    structure to ideas for change that directly link stakeholder

    experiences of the current service system to a concrete vision

    of transformation and improved outcomes. Systems thinking

    also helps stakeholders identify strategic opportunities for

    change and supports a concrete transition from ideas to

    actionable steps. Ultimately, systems thinking allows

    stakeholders to use information in a way that provides flex-

    ibility and responsiveness to local conditions and supports

    learning over time. This grounding in learning is, perhaps,

    the most valuable aspect of SSM and systems thinking.

    Although the research team tracked the dissemination of

    research findings related to the conceptual model, the study

    design did not include tracking how communities put these

    findings to practical use in their systems change initiatives

    or the results of such efforts. We strongly believe that

    continued research examining the processes of systems

    change, in particular practically useful explorations to how

    change occurs, is important to a variety of complex com-

    munity initiatives including systems of care. Continued

    research and evaluation focused on the circumstances,contingencies, and actions that support and impede systems

    change is an important area of inquiry for systems of care

    and would be well served by community psychologys

    inter-disciplinary partnerships and community-engaged

    approaches.

    Acknowledgments This research was jointly funded by theNational Institute on Disability and Rehabilitation Research, U.S.Department of Education and the Center for Mental Health Services,Substance Abuse and Mental Health Services Administration undergrant number H133B040024.The USF research team wishes to thankour partners in the State of Hawaii, Marion County, IN, Placer

    County, CA, Region 3, NE, Santa Cruz County, CA, and WestchesterCounty, NY for their generous collaboration and thoughtful contri-butions to this work.

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